The need for an independent evaluation of the COVID-19 response in Spain

Spain has been hit hard by COVID-19, with more than 300 000 cases, 28 498 confirmed deaths,¹ and around 44 000 excess deaths, as of Aug 4, 2020.² More than 50 000 health workers have been infected, and nearly 20 000 deaths were in nursing homes.³ With a population of 47 million, these data place Spain among the worst affected countries. Spain is also reported to have one of the best performing health systems in the world⁴ and ranks 15th in the Global Health Security index.⁵ So how is it possible that Spain now finds itself in this position?

Potential explanations point to a lack of pandemic preparedness (ie, weak surveillance systems, low capacity for PCR tests, and scarcity of personal protective equipment and critical care equipment), a delayed reaction by central and regional authorities, slow decision-making processes, high levels of population mobility and migration, poor coordination among central and regional authorities, low reliance on scientific advice, an ageing population, vulnerable groups experiencing health and social inequalities, and a lack of preparedness in nursing homes. These problems were exacerbated by the effects of a decade of austerity that had depleted the health workforce and reduced public health and health system capacities.

A comprehensive evaluation of the health and social care systems is now needed to prepare the country for further waves of COVID-19 or future pandemics, identifying weaknesses and strengths, and lessons learnt. We are calling for an independent and impartial evaluation by a panel of international and national experts, focusing on the activities of the Central Government and of the governments of the 17 autonomous communities. This evaluation must include three areas: governance and decision making, scientific and technical advice, and operational capacity. Moreover, the social and economic circumstances that have contributed to making Spain more vulnerable, including rising inequalities, must be considered.

Specific concerns include public health functions, leadership and governance, financing, health and social workforce, health information systems, service delivery, access to diagnosis and treatment, the role of scientific research, and the experience and values of individuals, communities, and vulnerable groups.

This evaluation should not be conceived as an instrument for apportioning blame. Rather, it should identify areas where public health and the health and social care system need to be improved. Although this type of evaluation is not usual in Spain, several institutions and countries, such as WHO⁶ and Sweden,⁷ have accepted the need for such a review as a means towards learning from the past and preparing for the future.

We encourage the Spanish Government to consider this evaluation as an opportunity that could lead to better pandemic preparedness, preventing premature deaths and building a resilient health system, with scientific evidence at its core.

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